Nursing Assignment: Developing a Care Plan for a Patient with Cystic Fibrosis

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student:
Name of the University:
Author Note:

1NURSING ASSIGNMENT
Introduction:
The patient information that Nurses receive during patient admission is voluminous
and at the same time haphazard. In order to plan and devise an appropriate intervention plan
there is a need to organize the data and document it in a clear manner. According to Forrester
et al. (2014), SOAP notes help Nurses to retrieve important information and eliminate the rest
so as to draft a care plan (Forrester, 2014). The SOAP stands for subjective data, Objective
data, Assessment and Plan. This assignment would present the SOAP data of JR who is
diagnosed with cystic fibrosis and use the data to prepare a nursing care plan.
S (Subjective Data):
 Patient reported at the outpatient clinic for biannual evaluation
 Patient diagnosed with Cystic fibrosis
 Patients reports about not having a good feeling
 Patient reports to have skipped the last week at school
 Patient reports low energy
 Patient reports frequent coughing and having a hard time to breathe
 Family History:
 Patient is 13 year old and stays with his parent
 Patient has a 7 year old sister who is also diagnosed with Cystic fibrosis
O (Objective Data): Documented vital signs of the patient:
 Blood pressure: 115/76
 Pulse rate: 85
 Respiratory Rate: 28
 Temperature: 101.8 ̊ F/ (38.8 ̊ C)

2NURSING ASSIGNMENT
 SPO2: 88% (room temperature)
 Body weight: 30 kg
 Appearance: Pale and dry. Nails appear bluish and clubbed.
Symptoms: The patient’s respiratory effort seemed laboured. The patient was seen to cough
(productively) with rhonchi. The patient’s thorax displayed a barrel-chest appearance. The
patient appeared thin and weak with diminished muscular mass. The pain score was
documented as 3 to 4 out of 10. Normal bowel functioning noted. Patient appeared anxious
and answered questions in short phrases.
A (Assessment):
 The patient looked weak and fragile
 The patient experienced difficulty while breathing
 The patient seems very anxious and low in mood
 The patient is experiencing pain while coughing
 The patient seems to be have an infection within the respiratory tract
P (Plan):
Medication:
 Ceftazidime (Fortaz) 2g IV push
 Gentamicin (Gentak) 100 mg IV q8hr
 Vancomycin (Vancocin) 450mg IV q8hr
Education:
 Educate the patient and the family members of the patient about the current medical
condition of JR (Haller et al., 2014)
 Provide education about cystic fibrosis and the treatment options available